Cardiovascular Lipid Risk Factors and Rate of Cardiovascular Events After Myocardial Revascularization

Cosor Oana Catalina Bucur Adina Baibata Emilia Dana Smarandita Dragomir Angela Gaita Dan Mancas Silvia About the authors

Abstract

Background:

Coronary heart disease is a public health problem, and the leading cause of premature death in Europe and worldwide. There is epidemiological evidence that the control of cardiovascular risk factors following myocardial revascularization remains suboptimal.

Objectives:

Analyze the incidence of cardiovascular events in patients receiving secondary prevention therapies after myocardial revascularization.

Methods:

Single-center study on consecutive coronary patients retrospectively identified, conducted at the Institute of Cardiovascular Diseases in Timisoara, Romania. Patients with diagnosis of revascularization for coronary artery disease (percutaneous coronary intervention, PCI or coronary artery bypass grafting, CABG) were included, following the inclusion criteria of the EuroAspire IV study. Outcome measures were assessed at three time points- at T0, when myocardial revascularization was performed; at T1 (interview with patients who had undergone revascularization for more than 6 months and less than 5 years), and T2 (interview with patients who had undergone revascularization for more than 5 years). Associations of primary and secondary lipid targets with the rates of adverse cardiovascular events (MACE) were assessed at T2.

Results:

Of 375 coronary patients, 341 were included in the study. At T1, 5% and 34.9% of patients reached the LDL-c and non-HDL-c target respectively. MACE rate at T2 was 7.9% in a median of 4.33 years of follow-up. We found a positive, statically significant association between MACE rate and LDL-c at T1 (p = 0.039). There were significant differences in mean non-HDLc levels between MACE categories at T1 (p = 0.02). There was a significant association between mean non-HDL with the incidence of heart failure (p = 0.007), newly diagnosed diabetes (p = 0.017) and restenosis rate (p = 0.004).

Conclusion:

The study highlights the need to control lipid risk factors after myocardial revascularization procedures, even at long-term, to minimize the risk of cardiovascular events in patients with coronary diseases.

Keywords:
Coronary Artery Disease; Risk Factors; Lipid; Metabolism; Myocardial Revascularization; Epidemiology

Resumo

Fundamentos:

A doença arterial coronariana é um problema de saúde pública, e principal causa de morte prematura na Europa e no mundo. Há evidência epidemiológica de que o controle dos fatores de risco cardiovasculares após a revascularização do miocárdio encontra-se ainda abaixo do desejável.

Objetivo:

Analisar a incidência de eventos cardiovasculares em pacientes em tratamento para prevenção secundária após revascularização do miocárdio.

Método:

Estudo unicêntrico com pacientes com doença coronariana consecutivos, identificados retrospectivamente. O estudo foi conduzido no Instituto de Doenças Cardiovasculares em Timisoara, Romênia. Os pacientes com diagnóstico de revascularização por doença arterial coronariana (intervenção coronária percutânea, ICP ou ponte de artéria coronária, CABG) foram incluídos, seguindo-se os critérios de inclusão do estudo EUROASPIRE IV. Os dados foram analisados em três momentos - T0, quando a revascularização do miocárdio foi realizada; T1 (entrevista com pacientes submetidos à revascularização há mais de 6 meses e menos de 5 anos); e T2 (entrevista com pacientes submetidos à revascularização há mais de 5 anos).

Resultados:

Dos 375 pacientes com doença coronariana, 341 foram incluídos no estudo. No T1, somente 5% e 34,9% dos pacientes atingiram os níveis desejáveis de LDL-c e não-HDL-c, respectivamente. A taxa de MACE em T2 foi de 7,9% em um tempo de acompanhamento mediano de 4,33 anos. Encontramos uma associação significativa positiva entre taxa de MACE e LDL-c em T1 (p = 0,039). Houve diferenças significativas nos níveis médios de não-HDL-c entre as categorias de MACE em T1 (p = 0,02). Valores médios de não-HDL associaram-se significativamente com a incidência de insuficiência cardíaca (p = 0,007), diabetes com diagnóstico recente (p = 0,017) e taxa de reestenose (p = 0,04).

Conclusão:

O estudo destaca a necessidade de se controlar fatores de risco relacionados ao perfil lipídico após procedimentos de revascularização do miocárdio, mesmo em longo prazo, a fim de minimizar o risco de eventos cardiovasculares em pacientes com doenças coronarianas.

Doença da Artéria Coronariana; Fatores de Risco; Lipídeos; Metabolismo; Revascularização Miocárdica; Epidemiologia

Introduction

Coronary heart disease remains "the scourge of the modern world" despite advances made in the field. It is a public health problem, and the leading cause of premature death in Europe and worldwide.11 Zengin E, Bickel C, Schnabel RB, Zeller T, Lackner KJ, Rupprecht HJ, et al; Athero Gene-Study Investigators. Risk factors of coronary artery disease in secondary prevention: results from the AtheroGene study. PLoS One. 2015;10(7):e0131434.

In this study, we focused on understanding the evolution of the atherothrombotic process in coronary symptomatic patients who underwent coronary revascularization: percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).

The relationship between low-density lipoprotein cholesterol (LDL-c) and the incidence of cardiovascular events has been demonstrated by numerous epidemiological studies: CARDS22 Colhoun HM, Betteridge DJ, Durrington PN, Hitman GA, Neil HA, Livingstone SJ, et al; CARDS investigators. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo controlled trial. Lancet. 2004;364(9435):685-96. ASPEN33 Knopp RH, d'Emden M, Smilde JG, Pocock SJ. Efficacy and safety of atorvastatin in the prevention of cardiovascular end points in subjects with type 2 diabetes: the Atorvastatin Study for Prevention of Coronary Heart Disease Endpoints in non-insulin-dependent diabetes mellitus (ASPEN). Diabetes Care. 2006;29(7):1478-85. ASCOT.44 Peter S. Sever PS, Poulter NR Dahlöf B, Wedel H. Different time course for prevention of coronary and stroke events by atorvastatin in the Anglo-Scandinavian CArdiac Outcomes Trial-Lipid-Lowering Arm (ASCOT-LLA). Am J CArdiol. 2005;96(5A):39F-44F. The New European Society of Cardiology (ESC) Guidelines for Cardiovascular Disease Prevention recommended LDL-c target levels of lower than 70 mg/dL for coronary patients at high risk and very high risk55 Piepoli MF, Hoes AW, Agerwall S, Albus C, Brotons C, Catapano AL, et al; Authors/Task Force Members. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37(29):2315-81.. In addition, patients under statin therapy may also be at very high cardiovascular risk.55 Piepoli MF, Hoes AW, Agerwall S, Albus C, Brotons C, Catapano AL, et al; Authors/Task Force Members. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37(29):2315-81.-66 Kotseva K, Wood D, De Bacquer D, De Backer G, Rydén L, Jennings C, et al; EUROASPIRE Investigators. EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries. Eur J Prev Cardiol. 2016;23(6):636-48.

The EuroAspire III and IV trials represent the epidemiological evidence that the control of modifiable cardiovascular risk factors among coronary patients remains suboptimal.66 Kotseva K, Wood D, De Bacquer D, De Backer G, Rydén L, Jennings C, et al; EUROASPIRE Investigators. EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries. Eur J Prev Cardiol. 2016;23(6):636-48.-77 Kotseva K, Wood D, De Backer G, De Bacquer D, Pyörälä K, Keil U; EUROASPIRE Study Group. EUROASPIRE III: a survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from 22 European countries. Eur J Cardiovasc Prev Rehabil. 2009;16(2):121-37.

The hypothesis of our research was that an inefficient control of cardiovascular risk factors would have a long-term effect on the incidence of fatal and non-fatal cardiovascular events. In this context, our study aimed to analyze the incidence of fatal and non-fatal cardiovascular events in coronary patients under statin therapy years after coronary revascularization, following the ESC prevention of cardiovascular disease program criteria.55 Piepoli MF, Hoes AW, Agerwall S, Albus C, Brotons C, Catapano AL, et al; Authors/Task Force Members. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37(29):2315-81.

Methods

This is a single-center study conducted at the Institute of Cardiovascular Disease, Timisoara, Romania. The inclusion criteria followed the EUROASPIRE IV protocol. A total of 375 consecutive coronary patients aged 18-80 years with definite diagnosis of revascularization for coronary artery disease (PCI, CABG) were retrospectively identified. Of them, 341 were considered eligible and 341 were included in the study (Figure 1). Clinical data of patients were assessed at three time points - at T0, when successful revascularization was identified, at T1 (from 6 months to 3 years post-myocardial revascularization), and at T2 (from 3 to 5 years post-myocardial revascularization).

Figure 1
Study design; PTCA: percutaneous transluminal coronary angioplasty; MACE: major adverse cardiovascular events; CABG: coronary artery bypass grafting

The following data was collected on an electronic database: lipid profile data - total cholesterol (TC); triglycerides, (TG); high-density lipoprotein cholesterol (HDL-c); LDL-c; non-HDL-c calculated as TC minus HDL-c88 National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106(25):3143-421. - number of fatal / non-fatal cardiovascular events; major adverse cardiovascular events (MACE): cardiovascular death, noncardiovascular death, restenosis, stroke / transient ischemic attack (TIA) - electrostimulation by pacemaker, hospitalization for reintervention - percutaneous transluminal coronary angioplasty (PTCA) or CABG, hospitalization for heart failure, diagnosis of diabetes mellitus. New lipid risk was evaluated at T0 and T1, following the European Cardiovascular Prevention criteria (5). The rate of fatal and nonfatal cardiovascular events was analyzed based on the potential cardiolipidic risk.

Patients' follow-up was conducted by a questionnaire validated for the countries that participated in the EUROASPIRE IV study.66 Kotseva K, Wood D, De Bacquer D, De Backer G, Rydén L, Jennings C, et al; EUROASPIRE Investigators. EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries. Eur J Prev Cardiol. 2016;23(6):636-48. At inclusion, we used the post-revascularization protocols specified in the ESC guidelines for secondary cardiovascular prevention (2012)99 Cosor OC, Baibata DE, Iurciuc S, Velimirovici D, Duda-Seiman D, et al. Cardiovascular risk profile of remote process of coronary dezobstruction. In: Center of Promoting Health Education and Motivation for Prevention in Dentistry Center for Continuous Medical Education.Timisoara: WALDPRESS: 2016. (Medicine in Evolution volume XXII, nº3)., adopted by the Romanian Society of Cardiology.

Statistical analysis

Statistical analysis was performed with SPSS 17.0 statistics, including 31 statistical variables (numerical and categorical). Time variable was calculated from the date the patient underwent coronary revascularization until January 2015, when MACE events were detected as present or absent. Normality of the variables was tested by the Shapiro- Wilk test. Differences between variables with only two categories were assessed by the non-parametric Mann-Whitney test. A p-value < 0.05 was set as statistically significant.

Results

Of 375 consecutive coronary patients, 341 patients (64.22 ± 8.90 years, 81.52% male) were included in our study. Baseline characteristics of patients are presented in Table 1.

Table 1
Baseline characteristics of patients (n = 341)

At T0, 52.5% of patients had undergone CABG, 43.1% PCI, and 4.4% had undergone both procedures.

At inclusion in the study, there was a high prevalence of modifiable cardiovascular risk factors (Table 1.1).

Table 1.1
Evaluation of cardiovascular risk factors atT0 (n = 341)

Statin therapy for LDL-c control remains a pertinent therapeutic target (Table 2)

Table 2
Lipid target levels and number of patients in whom these levels were reached at T1

At T1, 76.2% of participants had LDL-c values ≥ 80 mg/dL. In fact, only 5% of revascularized patients receiving statins that reached the target LDL-c value recommended by the ESC guidelines.55 Piepoli MF, Hoes AW, Agerwall S, Albus C, Brotons C, Catapano AL, et al; Authors/Task Force Members. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37(29):2315-81.,1010 Perk J, De Backer G, Gohlek H, Graham I, Reiner Z, Verschuren WM, et al; Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice.; European Association for Cardiovascular Prevention and Rehabilitation. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012): The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Atherosclerosis. 2012;223(1):1-68.,1111 Reiner Z, Catapano AL, De Backer G, Graham I, Taskinen MR, Wiklund O, et al; ESC Committee for Practice Guidelines (CPG) 2008-2010 and 2010-2012 Committees. ESC/EAS guidelines for the management of dyslipidemias: the task force for the management of dyslipidemias of European Society of Cardiology (ESC) and the European Atherosclerosis Society ( EAS). Eur Heart J. 2011;32(14):1769-818.

Non-HDLc or secondary lipid target and residual risk: using a non-HDL-c target < 110 mg/dL, we found that 30.8% of patients at T0 and 34.9% at T1 achieved these levels (p = NS) dL. There was no statistically significant differences between mean non-HDL-c atT0 (135.2 ± 44.95 mg/dL) and T1 (129.13 ± 40.9 mg/dL).

MACE rates and post-revascularization cardiovascular risk: the MACE rate at T2 was 7.9% in a median follow-up time of 4.33 years.

There was a positive and statistically significant association between primary lipid target of LDL-c at T1 and MACE (p = 0.039, chi test, 95% CI) (Table 3). In addition, there was a significant difference in mean non-HDL-c between the MACE categories at T1 (p = 0.02, Kruskal Wallis test, 95% CI) (Figure 2).

Table 3
Relationship between LDL-c and major adverse cardiovascular events (MACE) at T1

Figure 2
Mean LDL-c levels at T1 and major adverse cardiovascular events (MACE) rate at T2

Restenosis rate was 0.9% and was significantly influenced by average non-HDLc (p = 0.04, Mann-Whitney test, 95% CI).

The incidence of heart failure, defined by the value of ejection fraction was significantly higher in patients with increased non-HDL-c, not responsive to medications at T1 (p = 0.007, Mann-Whitney test, 95% CI).

Newly diagnosed cases of diabetes were significantly more frequent in patients with increased non-HDL-c at T1 (p = 0.017, Mann-Whitney test, 95% CI).

There was no significant difference between the incidence of MACE and the type of revascularization procedures.

Discussion

Our study demonstrates a high cardiovascular risk among coronary patients after 4.33 years of myocardial revascularization.

The drugs prescribed to be used in association with statins were platelet aggregators, beta-blockers, angiotensin converting enzyme inhibitors and angiotensin receptor blockers, in accordance with the ESC guidelines for secondary cardiovascular prevention.

Analysis of the relationship between the medications and achievement of target values of modifiable risk factors was previously published by our group.99 Cosor OC, Baibata DE, Iurciuc S, Velimirovici D, Duda-Seiman D, et al. Cardiovascular risk profile of remote process of coronary dezobstruction. In: Center of Promoting Health Education and Motivation for Prevention in Dentistry Center for Continuous Medical Education.Timisoara: WALDPRESS: 2016. (Medicine in Evolution volume XXII, nº3). Reduction in systolic blood pressure under medication was achieved in 39.58% of subjects enrolled in this study; cardiometabolic risk was reduced under the maximum dose of statin. Although the primary lipid target was reached in only 5% of patients, better outcomes were found in the secondary lipid target, non-HDL-c.

The high metabolic risk in these coronary patients is supported by dyslipidemia and high incidence of diabetes at T1, which justifies the implementation of energetic approaches toward lifestyle changes associated with the use of proper medication in revascularized patients.

Our study did not set out to analyze the compliance of patients to post-revascularization recovery programs, which would have contributed to interpretation of our results. A low compliance to these programs and cardiovascular preventive approaches may be related to the development of atherothrombosis in coronary patients, and might explain the prevalence of cardiovascular events (7.9%) at T2 and a median survival time of 4.33 years in our study group. Further studies to evaluate the compliance of patients to these approaches would be helpful.

Our study corroborates the need for strategies to control modifiable cardiovascular risk factors.99 Cosor OC, Baibata DE, Iurciuc S, Velimirovici D, Duda-Seiman D, et al. Cardiovascular risk profile of remote process of coronary dezobstruction. In: Center of Promoting Health Education and Motivation for Prevention in Dentistry Center for Continuous Medical Education.Timisoara: WALDPRESS: 2016. (Medicine in Evolution volume XXII, nº3).,1212 EUROASPIRE. A European Society of Cardiology survey of secondary prevention of coronary heart disease: principal results. EUROASPIRE Study Group. European Action on Secondary Prevention through Intervention to Reduce Events. Eur Heart J. 1997;18(10):1569-82. Erratum in: Eur Heart J. 1998;19(2):356-7,1313 Reiner Z, De Backer G, Fras Z, Kotseva K, Tokgözoglu L, Wood D. EUROASPIRE Investigators. Lipid lowering drug therapy in patients with coronary heart disease from 24 European countries--Findings from the EUROASPIRE IV survey. Atherosclerosis. 2016;246:243-50. Despite the use of medications, patients undergoing myocardial revascularization remain at risk of cardiovascular events related to atherosclerosis progression and other metabolic diseases.99 Cosor OC, Baibata DE, Iurciuc S, Velimirovici D, Duda-Seiman D, et al. Cardiovascular risk profile of remote process of coronary dezobstruction. In: Center of Promoting Health Education and Motivation for Prevention in Dentistry Center for Continuous Medical Education.Timisoara: WALDPRESS: 2016. (Medicine in Evolution volume XXII, nº3).,1111 Reiner Z, Catapano AL, De Backer G, Graham I, Taskinen MR, Wiklund O, et al; ESC Committee for Practice Guidelines (CPG) 2008-2010 and 2010-2012 Committees. ESC/EAS guidelines for the management of dyslipidemias: the task force for the management of dyslipidemias of European Society of Cardiology (ESC) and the European Atherosclerosis Society ( EAS). Eur Heart J. 2011;32(14):1769-818.

Results from the EUROASPIRE IV66 Kotseva K, Wood D, De Bacquer D, De Backer G, Rydén L, Jennings C, et al; EUROASPIRE Investigators. EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries. Eur J Prev Cardiol. 2016;23(6):636-48. pointed out that the Joint European Societies Guidelines on Cardiovascular Prevention recommendations are achieved in a still low proportion of coronary patients across Europe. In our study, only a modest percentage of revascularized coronary patients met the ESC Guidelines recommendations for LDLc -targets.1010 Perk J, De Backer G, Gohlek H, Graham I, Reiner Z, Verschuren WM, et al; Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice.; European Association for Cardiovascular Prevention and Rehabilitation. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012): The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Atherosclerosis. 2012;223(1):1-68.,1111 Reiner Z, Catapano AL, De Backer G, Graham I, Taskinen MR, Wiklund O, et al; ESC Committee for Practice Guidelines (CPG) 2008-2010 and 2010-2012 Committees. ESC/EAS guidelines for the management of dyslipidemias: the task force for the management of dyslipidemias of European Society of Cardiology (ESC) and the European Atherosclerosis Society ( EAS). Eur Heart J. 2011;32(14):1769-818. Although statin was prescribed to nearly 95% of patients at T1, the LDL-c levels were not reached by most of them.

Reiner et al.1313 Reiner Z, De Backer G, Fras Z, Kotseva K, Tokgözoglu L, Wood D. EUROASPIRE Investigators. Lipid lowering drug therapy in patients with coronary heart disease from 24 European countries--Findings from the EUROASPIRE IV survey. Atherosclerosis. 2016;246:243-50. emphasized the need to reduce LDL-c levels after a cardiovascular event to reduce coronary heart disease mortality and morbidity.1313 Reiner Z, De Backer G, Fras Z, Kotseva K, Tokgözoglu L, Wood D. EUROASPIRE Investigators. Lipid lowering drug therapy in patients with coronary heart disease from 24 European countries--Findings from the EUROASPIRE IV survey. Atherosclerosis. 2016;246:243-50. Other authors suggested several reasons for the mediocre response during statin therapy: inadequate dose, non-adherence to prescribed dose, statin resistance and / or intolerance, and side effects.1414 Boekholdt SM, Arsenault BJ, Mora S, Pedersen TR, LaRosa JC, Nestel PJ, et al. Association of LDL cholesterol, non-HDL cholesterol, and apolipoprotein B levels with risk of cardiovascular events among patients treated with statins: a meta-analysis. JAMA. 2012;307(12):1302-9. Erratum in: JAMA. 2012;307(18):1915.,1515 Zambon A, Puato M, Faggin E, Grego F, Rattazzi M, Pauletto P. Lipoprotein remnants and dense LDL are associated with features of unstable carotid plaque: a flag for non-HDL-C. Atherosclerosis. 2013;230(1):106-9. However, our results confirm the association between increased LDL-c levels with cardiovascular event rates.

We wonder if we can predict residual lipid risk in revascularized, coronary patients in use of statins. In our study group, there were significant differences in mean HDL-c and MACE rates at T2 as compared with other time points. Furthermore, they were correlated with the rate of restenosis, prevalence of heart failure and incidence of diabetes. In ESC / European Atherosclerosis Society (EAS) guidelines recommend the use of non-HDL-c as secondary target, especially among diabetic coronary patients.1111 Reiner Z, Catapano AL, De Backer G, Graham I, Taskinen MR, Wiklund O, et al; ESC Committee for Practice Guidelines (CPG) 2008-2010 and 2010-2012 Committees. ESC/EAS guidelines for the management of dyslipidemias: the task force for the management of dyslipidemias of European Society of Cardiology (ESC) and the European Atherosclerosis Society ( EAS). Eur Heart J. 2011;32(14):1769-818.,1414 Boekholdt SM, Arsenault BJ, Mora S, Pedersen TR, LaRosa JC, Nestel PJ, et al. Association of LDL cholesterol, non-HDL cholesterol, and apolipoprotein B levels with risk of cardiovascular events among patients treated with statins: a meta-analysis. JAMA. 2012;307(12):1302-9. Erratum in: JAMA. 2012;307(18):1915.

15 Zambon A, Puato M, Faggin E, Grego F, Rattazzi M, Pauletto P. Lipoprotein remnants and dense LDL are associated with features of unstable carotid plaque: a flag for non-HDL-C. Atherosclerosis. 2013;230(1):106-9.
-1616 Widimský P, Zvárová J, Monhart Z, Janský P; ALERT-CZ Investigators. The use of revascularization strategies in patients with acute coronary syndromes admitted to hospitals without catheterization facilities: Results from the ALERT-CZ registry. Cor et Vasa. 2013;55(3):e207-11. It seems that non-HDL would be a better predictor than LDLc of unstable atherosclerotic plaque.1717 Gyberg V, De Bacquer D, De Backer G, Jennings C, Kotseva K, Mellbin L, et al; EUROASPIRE Investigators. Patients with coronary artery disease and diabetes need improved management: a report from the EUROASPIRE IV survey: a registry from the EuroObservational Research Programme of the European Society of Cardiology. Cardiovasc Diabetol. 2015;14:133.

Reiner et al. reported that 12.2% of coronary patients in whom the LDLc target value was reached had pathological levels of non-HDL-c. In our sample, only 7.33% patients had non-HDL-c levels > 110 mg/dL and LDL-c < 80 mg/dL after myocardial revascularization.

The ESC/EAS guidelines recommend that patients with such changes in the lipid profile should be identified and treated as appropriate.1818 Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D'Agostino RB Sr, Gibbons R, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2935-59. Erratum in: J Am Coll Cardiol. 2014;63(25 Pt B):3026.

19 Rabar S, Harker M, O'Flynn N, Wierzbicki AS, Guideline Development Group. Lipid modification and cardiovascular risk assessment for the primary and secondary prevention of cardiovascular disease: summary of updated NICE guidance. BMJ. 2014;349:g4356.
-2020 Mega JL, Stitziel NO, Smith JG, Chasman DI, Caulfield MJ, Devlin JJ, et al. Genetic risk, coronary heart disease events, and the clinical benefit of statin therapy: an analysis of primary and secondary prevention trials. Lancet. 2015;385(9984):2264-71.

Our study has some limitations. First, baseline characteristics of participants were defined in a relatively late stage of coronary artery disease, i.e. at the time of myocardial revascularization. In addition, our sample was somewhat biased, since it was composed exclusively of patients treated at Timisoara Institute of Cardiovascular Diseases, which is a specialized treatment center, and therefore, the results cannot be to all patients with coronary revascularization. However, there were relatively small differences between our results with those of previous studies conducted in Europe.1616 Widimský P, Zvárová J, Monhart Z, Janský P; ALERT-CZ Investigators. The use of revascularization strategies in patients with acute coronary syndromes admitted to hospitals without catheterization facilities: Results from the ALERT-CZ registry. Cor et Vasa. 2013;55(3):e207-11.

17 Gyberg V, De Bacquer D, De Backer G, Jennings C, Kotseva K, Mellbin L, et al; EUROASPIRE Investigators. Patients with coronary artery disease and diabetes need improved management: a report from the EUROASPIRE IV survey: a registry from the EuroObservational Research Programme of the European Society of Cardiology. Cardiovasc Diabetol. 2015;14:133.

18 Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D'Agostino RB Sr, Gibbons R, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2935-59. Erratum in: J Am Coll Cardiol. 2014;63(25 Pt B):3026.

19 Rabar S, Harker M, O'Flynn N, Wierzbicki AS, Guideline Development Group. Lipid modification and cardiovascular risk assessment for the primary and secondary prevention of cardiovascular disease: summary of updated NICE guidance. BMJ. 2014;349:g4356.

20 Mega JL, Stitziel NO, Smith JG, Chasman DI, Caulfield MJ, Devlin JJ, et al. Genetic risk, coronary heart disease events, and the clinical benefit of statin therapy: an analysis of primary and secondary prevention trials. Lancet. 2015;385(9984):2264-71.
-2121 JBS3 Board. Joint British Societies' consensus recommendations for the prevention of cardiovascular disease (JBS3). Heart. 2014;100 Suppl 2:ii1-ii67.

Conclusions

The study highlights the need to control lipid risk factors after myocardial revascularization procedures, even at long-term, to minimize the risk of cardiovascular events in patients with coronary diseases.

  • Sources of Funding
    This study was partially funded by Astrazeneca (Research Grants Unrestricted to the European Society of Cardiology).
  • Study Association
    This article is part of the thesis of Doctoral submitted by Cosor Oana Catalina, from University of Medicine and Pharmacy Victor Babes Timisoara.

References

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    Zengin E, Bickel C, Schnabel RB, Zeller T, Lackner KJ, Rupprecht HJ, et al; Athero Gene-Study Investigators. Risk factors of coronary artery disease in secondary prevention: results from the AtheroGene study. PLoS One. 2015;10(7):e0131434.
  • 2
    Colhoun HM, Betteridge DJ, Durrington PN, Hitman GA, Neil HA, Livingstone SJ, et al; CARDS investigators. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo controlled trial. Lancet. 2004;364(9435):685-96.
  • 3
    Knopp RH, d'Emden M, Smilde JG, Pocock SJ. Efficacy and safety of atorvastatin in the prevention of cardiovascular end points in subjects with type 2 diabetes: the Atorvastatin Study for Prevention of Coronary Heart Disease Endpoints in non-insulin-dependent diabetes mellitus (ASPEN). Diabetes Care. 2006;29(7):1478-85.
  • 4
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Publication Dates

  • Publication in this collection
    Jan-Feb 2017

History

  • Received
    03 Oct 2016
  • Reviewed
    21 Oct 2016
  • Accepted
    21 Nov 2016
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